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HomeMy WebLinkAboutG-12-687 MASSJ.CHUSE i,TS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ist=�t CITY I t rwrwl{h `� I MA DATE, 5////7- I PERMIT#6LI Z 'tot 1 Aso JOBSITEADDJJRESS ?R7 4✓hi-he f3 IOWNER'S NAME X10 A/o7hfnct frur��/ G _ Zvq OWNER ADDRESS 0.a. lbx 77f Pavia 0Nr9P 1TEL 'FAX 1 Tp NOR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL❑ RESIDENTIAL CI CLEARLY NEW:2(RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO[y� APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .I 1 _11.. __I . . . I BOOSTER II_ - , L � [MIIII I CONVERSION BURNER II„ II ,1 In (' � lint M COOK STOVE 11 1 1 . 1 1W n d _I 0- DIRECT VENT HEATER )1171.- -.nil I „fl__,_ �I ,-....1 _ '911 M-Itr WI DRYER 11 11 1F- 11— II f „Ili 1 tt , o1:11- FIREPLACE !f .. t11 . IIS., Q „_. i �f FRYOLATOR � r1 Ir. _II If t(- I I I '8 GENERATOR CJRs pD, �1,-11,-�L -,1_, Il 1_,,..1 . , ,.�A(„ IT1 . �_„-.II7. ,.I1-- 11 INFRARED HEATER 9 LABORATORY COCKS I” t1 If I ,,,, Il f_ -11 1 i v^z� *'^9TW 1n � v v iry+.a Lin.,I R rf MAKEUP AIR UNIT „II,.. I I.'BI t( II, I , r(�I ,, = iI ,I�1 ,w_I POOLHSPACEHEATER Ir - II -__.Ir-I Tr l I I (-t m 1 �. 7 I ���I OVEN _,„„,1j1_,,,,11 �� POOL HEATER ��la. 1 1 fi_" PI 11 �I YI�-_ I,_"�,I ROOF TOP UNIT II If - II �,I (—J1-1 ,�H I 1—,I _.,.Il I' _,_ TEST .-1 {I I , 11 – fir„,,:, p� ( r- 11 k UNIT HEATER „,. 111.11,, r 1 1 ' 1 -1 _II 4 �w �nixai .. vl'L int UNVENTED ROOM HEATER II II j1- I r�� ��y�� I WATER HEATER U . M _. 1 OTHER 1 . f i__ I_— 1 ! ___ -I --"fnwrukt:C=COVEI'vACI I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ." /-4K /J-/ _ /i PLUMBER-GASFITTER NAME LICENSE# MY I SIGNATURE MP MGF❑ JP JGFQ LPGI❑ CORPORATION al /74•2-C PARTNERSHIP❑# LLC❑# COMPANY NAME: remit/6 . tc. I ADDRESS 22y MW- Lei, ak CITY W. Yprnte I STATE 0 U ZIP 473 TEL S , &- 771/703 FAX Sob-Y1 /}1QJ CELL "' ,EMAIL I